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Lower extremity muscle strength, and functional limitations are important modifiable predictors of falls, but are often examined using performance based measures. We examined the association between self-reported physical function limitations, determined using Late-Life Function and Disability Instrument(LLFDI) and incident falls in community-dwelling elderly individuals. 283 older adults participants were included in this analysis. Physical function limitations were defined as a person’s difficulty in completing items of the lower extremity function domain and composite scores of the LLFDI. Information on falls was obtained through a standardised questionnaire. At one-year follow-up, 15.2% (43) of the participants experienced their first fall. In the multivariable analysis, individuals who reported difficulties in items of lower extremity function domain were more likely to experience a fall (incidence rate ratio[IRR]: ranging between 2.43 and 7.01; all P ≤ 0.046). In addition, decreasing advanced lower extremity function scores (IRR: 1.70, 95% confidence interval[CI]): 1.04, 2.78) and overall function component score (IRR: 2.05, 95% CI: 1.22, 3.44) were associated with higher risk of incident falls. Physical function limitations, determined using LLFDI, were associated with incident falls. Our findings provide further evidence that the LLFDI function component has the potential to be used as a self-assessment tool for fall risk.

Background Frailty is increasing in prevalence internationally with population ageing. Frailty can be managed or even reversed through community-based interventions delivered by a multi-disciplinary team of professionals, but to varying degrees of success. However, many of these care models’ implementation insights are contextual and may not be applicable in different cultural contexts. The Geriatric Service Hub (GSH) is a novel frailty care model in Singapore that focuses on identifying and managing frailty in the community. It includes key components of frailty care such as comprehensive geriatric assessments, care coordination and the assembly of a multi-disciplinary team. This study aims to gain insights into the factors influencing the development and implementation of the GSH. We also aim to determine the programme’s effectiveness through patient-reported health-related outcomes. Finally, we will conduct a healthcare utilisation and cost analysis using a propensity score-matched comparator group. Methods We will adopt a mixed-methods approach that includes a qualitative evaluation among key stakeholders and participants in the programme, through in-depth interviews and focus group discussions. The main topics covered include factors that affected the development and implementation of each programme, operations and other contextual factors that influenced implementation outcomes. The quantitative evaluation monitors each programme’s care process through quality indicators. It also includes a multiple-time point survey study to compare programme participants’ pre- and post- outcomes on patient engagement, healthcare services experiences, health status and quality of life, caregiver burden and societal costs. A retrospective cohort study will compare healthcare and cost utilisation between participants of the programme and a propensity score-matched comparator group. Discussion The GSH sites share a common goal to increase the accessibility of essential services to frail older adults and provide comprehensive care. This evaluation study will provide invaluable insights into both the process and outcomes of the GSH and inform the design of similar programmes targeting frail older adults. Trial Registration ClinicalTrials.gov Identifier NCT04866316. Date of Registration April 26, 2021. Retrospectively registered.

Background: The Singapore national Advance Care Planning (ACP) programme was launched in 2011 with the purpose of ensuring that healthcare professionals are fully aware of patients’ treatment preferences. There is little research assessing the performance of such programmes in ethnically diverse Asian countries; hence, the purpose of this study was to qualitatively examine patients and caregivers’ experiences with the ACP programme. Method: We conducted interviews with 28 participants, thirteen of whom identified as proxy decision makers (PDMs) and the remainder as patients. Interviews focused on respondents’ experiences of chronic illness and of participating in the ACP programme. Textual data was analysed through a framework analysis approach. Results: Participants’ narratives focused on four major themes with 12 subthemes: a) Engagement with Death, factors influencing respondents’ acceptance of ACP; b) Formation of Preferences, the set of concerns influencing respondents’ choice of care; c) Choice of PDM, considerations shaping respondents’ choice of nominated health spokesperson; and d) Legacy Solidification, how ACP is used to ensure the welfare of the family after the patient passes. These findings led to our development of the directive decision-making process framework, which delineates personal and sociocultural factors influencing participants’ decision-making processes. Respondents’ continual participation in the intervention were driven by their personal belief system that acted as a lens through which they interpreted religious doctrine and socio-cultural norms according to their particular needs. Conclusion: The directive decision-making process framework indicated that ACP could be appropriate for the Asian context because participants displayed an awareness of the need for ACP and were able to develop a concrete treatment plan. Patients in this study made decisions based on their perceived long-term legacy for their family, who they hoped to provide with a solid financial and psychological foundation after their death. Published version Research for this paper was supported by the Agency for Integrated Care Singapore, which receives public funding from the Ministry of Health of the Singaporean Government. The funder has played no role in the study design; collection, analysis or interpretation of data, or preparation of the manuscript.

Background Frailty is frequently found to be associated with increased healthcare utilisation in western countries, but little is known in Asian population. This study was conducted to investigate the association between frailty and healthcare utilisation by care setting among community-dwelling older adults in Singapore.Methods We conducted a six-month look-back and six-month post-baseline analysis of healthcare utilisation. Data from a longitudinal population-based survey were linked with healthcare utilisation data obtained from an administrative database. Baseline frailty status was measured using the five-item FRAIL scale, which is categorised into three groups: robust (0), pre-frail (1–2), and frail (3–5). Healthcare utilisation included government primary care clinic visits, specialised outpatient clinic visits, emergency department visits, day surgery and hospitalisations. Multivariable logistic and negative binomial regression were applied to examine the associations between frailty with healthcare utilisation, controlling for other confounding variables. Results In our sample of 701 older adults, 64.8% were of robust health, 27.7% belonged to the pre-frail category, and 7.6% were frail. Compared to the non-frail group, frail individuals had a higher rate of specialised outpatient clinic visits (incidence rate ratio (IRR): 2.8, 95% confidence interval (CI): 1.2-6.5), emergency department visits (IRR: 3.1, 95%CI: 1.1-8.1), day surgeries done (IRR: 6.4, 95%CI: 1.3-30.9), and hospitalisations (IRR: 6.7, 95%CI: 2.1-21.1) in the six-months before the baseline and in subsequent six months (IRR: 3.3, 95%CI: 1.6-7.1; 6.4, 2.4-17.2; 5.8, 1.3-25.8; 13.1, 4.9-35.0; respectively). Frailty was also significantly associated with an increased in the number of specialised outpatient clinic visits, emergency department visits and hospitalisations in 6 months before and after baseline, with controlling for covariates. Conclusions Among community-dwelling adults, frailty was positively associated with the likelihood and the number of specialised outpatient clinic visits, emergency department visits, day surgeries and hospitalisations but no significant associations were observed with primary care utilization. The positive association was significant at 6-month before and after the baseline. As frailty is a potentially reversible health state with early screening and intervention, providing preventive activities that delay the onset or progression of frailty should have the potential effect on delaying secondary and tertiary care needs.

Background: Terminally ill patients at the end-of-life do transit between care settings due to their complex care needs. Problems of care fragmentation could result in poor quality of care. Aim: We aimed to evaluate the impact of an integrated hospice home care programme on acute care service usage and on the share of home deaths. Settings/participants: The retrospective study cohort comprised patients who were diagnosed with cancer, had an expected prognosis of 1 year or less, and were referred to a home hospice. The intervention group comprised deceased patients enrolled in the integrated hospice home care programme between September 2012 and June 2014. The historical comparison group comprised deceased patients who were referred to other home hospices between January 2007 and January 2011. Results: There were 321 cases and 593 comparator subjects. Relative to the comparator group, the share of hospital deaths was significantly lower for programme participants (12.1% versus 42.7%). After adjusting for differences at baseline, the intervention group had statistically significantly lower emergency department visits at 30 days (incidence rate ratio: 0.38; 95% confidence interval: 0.31–0.47), 60 days (incidence rate ratio: 0.61; 95% confidence interval: 0.54–0.69) and 90 days (incidence rate ratio: 0.69; 95% confidence interval: 0.62–0.77) prior to death. Similar results held for the number of hospitalisations at 30 days (incidence rate ratio: 0.48; 95% confidence interval: 0.40–0.58), 60 days (incidence rate ratio: 0.71; 95% confidence interval: 0.62–0.82) and 90 days (incidence rate ratio: 0.77; 95% confidence interval: 0.68–0.88) prior to death. Conclusion: Our results demonstrated that by integrating services between acute care and home hospice care, a reduction in acute care service usage could occur.

Background : Many middle- and high-income countries face the challenge of meeting preferences for home deaths. A better understanding of associated factors could support the design and implementation of policies and practices to enable dying at home. This study aims to identify factors associated with the place of death in Singapore, a country with a strong sense of filial piety. Settings/participants : A retrospective cohort of 62,951 individuals (≥21 years old) who had died from chronic diseases in Singapore between 2012–2015 was obtained. Home death was defined as a death that occurred in a private residence whereas non-home deaths occurred in hospitals, nursing homes, hospices and other locations. Data were obtained by extracting and linking data from five different databases. Hierarchical multivariable logistic regression models were used to examine the effects of individual, clinical and system factors sequentially. Results : Twenty-eight percent of deaths occurred at home. Factors associated with home death included being 85 years old or older (OR 4.45, 95% CI 3.55–5.59), being female (OR 1.21, 95% CI 1.16–1.25), and belonging to Malay ethnicity (OR 1.91, 95% CI 1.82–2.01). Compared to malignant neoplasm, deaths as a result of diabetes mellitus (OR 1.93, 95% CI 1.69–2.20), and cerebrovascular diseases (OR 1.28, 95% CI 1.19–1.36) were also associated with a higher likelihood of home death. Independently, receiving home palliative care (OR 3.45, 95% CI 3.26–3.66) and having a documented home death preference (OR 5.08, 95% CI 3.96–6.51) raised the odds of home deaths but being admitted to acute hospitals near the end-of-life was associated with lower odds (OR 0.92, 95% CI 0.90–0.94). Conclusion : Aside from cultural and clinical factors, system-based factors including access to home palliative care and discussion and documentation of preferences were found to influence the likelihood of home deaths. Increasing home palliative care capacity and promoting advance care planning could facilitate home deaths if this is the desired option of patients. NMRC (Natl Medical Research Council, S’pore) MOH (Min. of Health, S’pore) Published version

Context One of the key outcomes of advance care planning is whether patients had received care that was consistent with their expressed goals and preferences. Objectives The aims of this study were to illustrate the feasibility of using routinely collected health care data that include hospital procedural codes, diagnosis-related codes, health services utilization, and death registry data and to ascertain the level of concordance between care received and the stated goals. Methods In this retrospective cohort study, medical treatments were ascertained using a combination of hospital procedural codes and diagnosis-related codes. Places of care were obtained by reviewing the sequence of health services used, and the place of death was obtained from the national death registry. To ascertain concordance, medical treatment, places of care, and place of death were compared against the individual's preferences. Results The sample includes 1731 decedents (aged 21 years and above) who completed their advance care planning documentation as part of a national program. Ninety-eight percent who wished for comfort measures met their preferences. Sixty-five percent of individuals who wished to be cared for at home received care at home. Nearly 40% of all individuals who opted to die at home achieved their wishes, whereas 76% of those who opted for home or hospital and home or hospice had their preferences fulfilled. Conclusion Administrative data offer a cost-efficient and powerful method for assessing outcomes for a large population-based national program. However, this approach is still at an early stage of development and needs to be further validated before it can be used at scale.

ObjectiveThe chronic obstructive pulmonary disease (COPD) integrated care pathway (ICP) programme was designed and implemented to ensure that the care for patients with COPD is comprehensive and integrated across different care settings from primary care to acute hospital and home. We evaluated the effectiveness of the ICP programme for patients with COPD.Design, setting and participantsA retrospective propensity score matched cohort study was conducted comparing differences between programme enrolees and propensity-matched non-enrolees in a Regional Health System in Singapore. Data on patients diagnosed with COPD who enrolled in the programme (n=95) and patients who did not enrol (n=6330) were extracted from the COPD registry and hospital administrative databases. Enrolees and non-enrolees were propensity score matched.Outcome measuresThe risk of COPD hospitalisations and COPD hospital bed days savings were compared between the groups using a difference-in-difference strategy and generalised estimating equation approach. Adherence with recommended care elements for the COPD-ICP group was measured quarterly at baseline and during a 2-year follow-up period.ResultsCompared with non-enrolees, COPD hospitalisation risk for ICP programme enrolees was significantly lower in year 2 (incidence rate ratio (IRR): 0.73; 95% CI 0.54 to 1.00). Similarly, COPD hospital bed days was significantly lower for enrolees in year 2 (IRR: 0.78; 95% CI 0.64 to 0.95). ICP programme patients had sustained improvements in compliance with all recommended care elements for patients with COPD. The overall all-or-none care bundle compliance rate had improved from 28% to 54%.ConclusionThe study concluded that the COPD-ICP programme was associated with reductions in COPD hospitalisation risk and COPD health utilisation in a 2-year follow-up period.

Introduction: Depression in the elderly is a major public health issue. Socioeconomic status (SES) and social support are strong risk factors for depression. This study aimed to investigate the influence of SES and social support in elderly depression, and the modifying effect of social support on the relationship between SES and depression. Materials and Methods: A community-based survey was conducted on residents ≥60 years old. Depressive symptoms were determined with scores ≥5 using the 15-item Geriatric Depression Scale (GDS). Multivariable logistic regression was performed to determine the odds ratio (OR) of depressive symptoms with respect to SES and social support, and interaction terms between the two variables. Results: Of 2447 responses analysed, 188 (7.8%) respondents had depressive symptoms. Living in 2-room housing, living alone/with a domestic helper, infrequent leisure time with children/grandchildren or being childless, and feeling socially isolated were independently associated with depressive symptoms. Relative to residents living with spouse and children in 4-/5-room housing, the highest ORs for depressive symptoms were those living with spouse and children in 2-room (OR: 3.06, P

ObjectiveTo describe the end-of-life care preferences of individuals, and to examine the influence of age and gender on these preferences.Design, setting and participantsA retrospective cohort study was conducted. Participants included all adults (≥21 years old) (n=3380) who had completed a statement of their preferences as part of a national Advance Care Planning (ACP) programme in Singapore. Data were extracted from the national and Tan Tock Seng Hospital ACP database.Main measuresEnd-of-life care preferences were obtained from the ACP document and differentiated by health status (healthy, chronically ill or diagnosed with advanced illnesses). To analyse the data, descriptive statistics and logistic regression analysis were used.ResultsAcross healthy and chronically ill patients, the majority did not opt for cardiopulmonary resuscitation (CPR) or other life-sustaining measures. Among individuals with advanced illnesses, 94% preferred not to attempt CPR but 69% still preferred to receive some form of active medical treatment. Approximately 40% chose to be cared for, and to die at home. Age and sex significantly predict preferences in those with advanced illnesses. Older age (>=75 years) showed higher odds for home as preferred place of care (OR 1.52; 95% CI 1.23 to 1.89) and place of death (OR 1.29; 95% CI 1.03 to 1.61) and lower odds for CPR (OR 0.31; 95% CI 0.18 to 0.54) and full treatment (OR 0.32; 95% CI 0.17 to 0.62). Being female was associated with lower odds for home as preferred place of care (OR 0.69; 95% CI 0.57 to 0.84) and place of death (OR 0.70; 95% CI 0.57 to 0.85) and higher odds for full treatment (OR 2.35; 95% CI 1.18 to 4.68).ConclusionThe majority preferred to not proceed with life-sustaining treatments, but there was still a strong preference to receive some form of limited treatment. Better understanding of end-of-life care preferences through ACP can better guide end-of-life care programme planning, and resource allocation decisions.

Background: Cost of informal care constitutes an important component of total dementia care cost. It also reflects resource utilization by patients and caregivers. We aim to quantify the informal cost of care for mild to moderate dementia patients.Methods: We recruited 165 patient–caregiver dyads with mild to moderate dementia. Informal care burden was assessed using the Resource Utilization in Dementia (RUD)-Lite instrument. A generalized linear model was fitted for association between cost of informal care and cognitive impairment, taking into account patient demographics, disease factors, and use of paid domestic help. Marginal estimates were obtained from the model for the purpose of illustration and discussion.Results: Total hours of informal care by primary caregiver doubled in moderate dementia patients, with 57.9% having paid domestic help to assist in care. Functional factors and use of paid domestic help were significantly associated with informal care costs. Costs were consistently higher for patients without paid domestic help for mild- and moderate dementia.Conclusion: This study demonstrates the informal care costs of caring for mild–moderate dementia patients in Singapore, with the unique cost savings provided by live-in paid domestic help, and potentially may aid policy-makers in allocation of resources and support to caregivers.

Objective We aim to determine whether healthcare costs for patients diagnosed with Type 2 Diabetes Mellitus (T2DM) are associated with the severity of diabetes complications as measured by the Diabetes Complication Severity Index (DCSI). Methods Retrospective cohort analysis was performed on a 2007 primary care cohort of T2DM patients. The DCSI is a 13-point scale, which comprises 7 categories of complications and their severity levels. Healthcare cost data from 2008 and 2009 were used as primary outcome. Inpatient and outpatient costs incurred for services consumed by patients within the provider network were included. Generalized linear model with log-link and gamma distribution was used to predict healthcare costs. Results Of the 59,767 T2DM patients, 2977 (5.0%) deaths occurred and 1336 (2.2%) were lost to follow up. Healthcare cost was strongly associated with increase in DCSI score. Compared to patients without complications, those with more complications (higher DCSI score) had an increased risk of higher healthcare costs. Risk ratio (RR) increased from 1.25 (95%CI: 1.19–1.32) for DCSI = 1 to 1.61 (1.51–1.72) for DCSI = 2; 2.10 (1.91–2.31) for DCSI = 3; 2.52 (2.21–2.87) for DCSI = 4 and 3.62 (3.09–4.25) for DCSI ≥ 5. As a continuous score, a one-point increase in the DCSI was associated with a cost increase of 27% (95%CI: 1.25–1.29). Conclusion The DCSI score is a useful tool for predicting direct healthcare costs. The DCSI can be used to triage high-risk patients for more focused secondary prevention interventions at primary care level, in a bid to lower overall healthcare costs.

Introduction: This study determines the extent of, and factors associated with, delayed discharges for stroke patients from inpatient rehabilitation. Materials and Methods: A retrospective cohort study utilising medical notes review was conducted at an inpatient rehabilitation centre in Singapore. Acute stroke patients (n = 487) admitted between March 2005 and December 2006 were studied. The primary measure was delayed discharge defi ned as an extension in inpatient stay beyond the planned duration. Factors associated with delays in discharge were categorised as individual, caregiver, medical and organisational. Results: There were a total of 172 delayed discharges (35.6%). The mean [standard deviation (SD)] length of stay was 40.5 days (SD, 19.5 days) and 25.8 days (SD, 11.4 days) for patients with delayed and prompt discharges, respectively. Mean extension of stay was 9.7 days (SD, 13.8 days). Caregiver-related reasons were cited for 79.7% of the delays whereas organisational factors (awaiting nursing home placement, investigations or specialist appointments) accounted for 17.4%. Four factors were found to be independently associated with delayed discharge: discharge to the care of foreign domestic helper, nursing home placement, lower admission Functional Independence Measure (FIM) motor score and discharge planning process. Conclusions: Our study suggests that caregiver and organisational factors were main contributors of delayed discharge. Targeted caregiver training and the provision of post-discharge support may improve the confidence of caregivers of patients with greater motor disability. The use of structured discharge planning programmes may improve the efficiency of the rehabilitation service. To reduce delays, problems with the supply of formal and informal post-discharge care must also be addressed. Key words: Caregiver, Discharge planning, Length of stay, Nursing home

Background The study objective was to compare physical function documented in the medical records with interview data, and also to evaluate hospital mortality predictions using pre-admission and on-admission functional status derived from these two data sources. Methods A prospective cohort study of 1402 subjects aged 65 years and older to the general medicine department of an acute care hospital was conducted. Patient-reported pre-admission and on-admission functional status for impairment in any of the five activities of daily living (ADLs) items (feeding, dressing, grooming, toileting and bathing), transferring and walking, were compared with those extracted from the medical records. For the purpose of mortality prediction, pre-admission and on-admission impairment in transferring from the two data sources were included in separate multivariable logistic regression models. We used a variable selection method that combines bootstrap resampling with stepwise backward elimination. Results For all ADL categories, the agreement between the data sources was good for pre-admission functional status (k: 0.53–0.75) but poor for on-admission status (k: 0.18–0.31). On-admission impairment was higher in the medical records than at interview for all basic ADLs. Using interview data as the gold standard, although sensitivity for pre- and on-admission ADLs was high (59–93%), specificity for on-admission status was poor (30–37%). The pre-admission models using interview data predicted mortality better than the model using medical records (c-statistic: 0.83 versus 0.82). Similar results were found for models incorporating on-admission functional status (c-statistic: 0.84 versus 0.81). However, the differences between the four models were not statistically significant. Conclusion Medical records can be a good source for pre-admission functional status but on-admission functional impairment was over-reported in the medical records. The discriminatory power of the hospital mortality prediction model was significantly improved with the incorporation of functional status information but it was not significantly affected by their time reference or source of data.

Tan WS, Heng BH, Chua KS, Chan KF. Factors predicting inpatient rehabilitation length of stay of acute stroke patients in Singapore. Objective To determine the predictors of hospital length of stay (LOS) of stroke patients at the point of admission. Design A retrospective cohort study. Setting An acute hospital rehabilitation center in Singapore. Participants Stroke patients (N=491) admitted between March 2005 and December 2006. Interventions None. Main Outcome Measures Rehabilitation LOS was calculated as the total number of rehabilitation days before discharge. We measured the functional status of patients by using the Functional Independence Measure (FIM). Results The median LOS was 29 days (mean = 30.8d). Independent clinical and sociodemographic characteristics found to significantly predict rehabilitation LOS were FIM motor score at admission, the presence of more than 3 comorbid conditions at admission, living with nonimmediate relatives before admission, and the hospital subsidy status of the patient. In particular, the admission FIM motor score explained 43% of the variation in LOS and decreased the LOS by approximately 1.1 days for each 1-point increase in score. Conclusion Patients' socioeconomic status and family structure was found to influence LOS and should be considered in allocating resources and determining treatment need. The extent of motor function of patients at admission is an important factor influencing rehabilitation LOS and is a useful tool for facilitating rehabilitation resource planning for stroke patients.